If you all recall I went to Zurich in November to attend the “Concussion Conference”; mainly as an observer, but there was enough time and opportunity to impart my questions/knowledge as a practicing athletic trainer. Here are the links to DAY 1 and DAY 2 of my live blogging. By the way, the live blogging was WELL received and continues to provide great insight into what went on. I hope that I am asked back for the next conference, or any other conference that wouldn’t mind my attendance.
Now the information gathered at the conference has been hashed and rehashed and now appears as the 4th Consensus Statement (tweeted previously).
As part of the initiative the Standardized Concussion Assessment Tool (SCAT) was looked at and changes were made to the 2nd version from 2008. You can now find the new version by clicking SCAT3.
A new wrinkle was an assessment tool for the younger ages, the group decided on the “Child” version of the new SCAT3, that can also be found by clicking Child SCAT3.
Also included in the addendum of the Consensus Statement was a recognition pocket card, found by clicking Recognition Pocket Card.
All of the above is free and intended to be used as a resource for better concussion assessment and even early management of concussion. Please read the Statement regarding best practices. As always this blog is NEVER to be used to diagnose or treat a concussion. There is a lot to be absorbed and read; one thing is for sure we as athletic trainers and concerned/educated individuals now have the most recent information at our fingertips. I guess this blog is actually doing some good work 🙂 A side note; how about this appearing during National Athletic Trainers Month? It might be a coincidence, but I find it serendipitous.
The Concussion Blog 
Read it this morning. Just saved the SCAT3. We’ll see if we decide to switch to it or whether we choose to stick to the SCAT2. Personally, I’m not a big user of the SCAT2 either but rely more on signs/symptoms and clinical judgment.
Hop,
Agree, I most often use parts of many tools in my assessment… Really its the signs/symptoms reported and balance… Good ‘ol Rhombergs does a fine job as well… I am starting to think that this is becoming more of a convoluted mess, in terms of assessment…
Frankly, if you know about concussions, know the athlete and are there for immediate assessment, clinical judgement rules the day… However, we will NEVER see anyone admit that is best practice…
Keep it simple and stop muddying the water.
Committees build giraffes; I think Zurich has reached that stage.
I agree with Hopper and Fink that clinical judgment rules. Symptoms, balance, behavior, and patient knowledge guide diagnosis and treatment. Unfortunately, too few practitioners are highly skilled. In fact, Charles Tator stated during his medical training in the 1970s, “it was not considered serious.” Many docs still are stuck in the past along with coaches, parents and ATCs.
Hopefully before the next meeting the committee will be completely overwhelmed by the evidence that even single concussions can and does result in structural brain damage (so much for hit counts and magic helmets). There is clear evidence that micro-hemorrhaging in many cases as well as focal damage. The Guskiewicz, Derman, Herring, Kutcher and other NFL/NHL paid mouthpieces will simply have to fold the tent. (The MacArthur Foundation will have some splaining to do).
The research questions will turn to whether it is subclinical or clinical, long-term consequences and intervention. It is too bad the NFL is wasting its time and money on silly projects and players have put $100MM to never finding answers with Harvard. At least GE will make some cash by forcing schools to send every child to get a scan even if it has no clinical utility. Maybe, the NFL/NFLPA could put some money toward actually doing some real research by removing the lawyers for the equation. Barry Jordan, Cleveland Clinic, JHI etc, are all in the phone book and can probably move this field forward at a quick pace but I gather the fear of obtaining real answers to difficult questions will foreclose honest research from being conducted.
I disagree that NP testing is not valuable. It is crucial in subtle and complex cases. I gather the committee irresponsible marketing of ImPact as a magic bullet one could take at home. Pass and you are could to go. If one is conducting a thorough evaluation of a patient, it is an essential tool. Granted, a good tool in a fool’s hand is worthless.
Read about a study the other day where in a certain percentage of mTBI patients they found two types of lesions with MRI. There were “cerebral punctate microbleeds,” which I think are supposed to be characteristic of diffuse axonal injury and “linear-oriented streak-like lesions,” which are microbleeds likely caused by injury to vasculature. Not exactly sure of the ramifications of these types of microbleeds, but those types of findings would seem to indicate that concussion may be on a spectrum and the degree of structural damage can differ based on the forces involved in the injury.
To me, that kind of makes sense.
However, this morning I saw reference to a Swedish study that is supposed to turn the view of head injuries upside down. According to this Swedish study (going back to 1990’s), low cognitive function is probably a risk factor, and not a long term result of mTBI. Now, I could see how low cognitive function could be a risk factor in certain accidents, but don’t understand how it can be argued that damaging the brain couldn’t possibly reduce cognitive function (thought we already knew mTBI/TBI could do that). Just hope athletes now aren’t totally blamed for their injuries (told they most likely had low cognitive function to begin with and also a genetic predisposition to long-term problems).
Anyway, I understand your criticism of hit counts, yet still can’t help but think it would at least be better to make sure kids get hit in the head less than they are now. Think it’s going to take a long time for this issue to play out, and would like to at least see incremental improvements (without those improvements used to convince parents certain activities are “safe”).
Could you cite the Swedish study? I think you may be misinterpreting there conclusions. If the conclusion is that subjects with low IQ/cognitive reserve are more likely to have more neurological issues long-term, this has been long established. On the other hand, suggesting if a subject has a low IQ/cognitive reserve implies more TBIs makes little sense.
Didn’t read actual study – but here’s link to news release (it was tweeted out this morning by MomsTEAM):
http://www.alphagalileo.org/ViewItem.aspx?ItemId=129308&CultureCode=en
6th paragraph –
“The results show that low cognitive function is probably a risk factor for, and not a long term result of, mild traumatic brain injury.”
There’s a link to actual study at end of news release:
http://www.bmj.com/content/346/bmj.f723
Not sure if this study should be applied to sports. For everyday life, just as drivers can be put into different risk categories based on age & past driving history – there could be an association with less cognitive function/history of alcohol consumption/socioeconomic status and the risks/risky behaviors certain individuals would engage in (just guessing).
I think the study has a more important flaw. The researchers’ has not accounted for difference in risk between military occupation specialties (MOSs). For example, recruits with higher IQs may be tasked with less risky jobs. Lower IQs may be tasked with grunt infantry positions that take a battering.
The researchers don’t seem to have accounted for these differences and therefore the causation may be correctly attributed.
Good point – think the study needs to be looked at closely.
A Concerned Mom- you are correct A concussion, or mTBI, is the same type of injury as diffues axonal injury. The mechanism of injury is the same, the difference is in severity of injury. Typically in concussion the CT and MRI are normal. In DAI the CT is often normal but the MRI will show the changes you mentioned above. If you know anything about DAI, you know it is a catistrophic injury often resulting in death. I am not sure which study you were reading but if the patients had changes on the MRI they likely were suffering from more then just a concussion. This is why concussions get labeled as mTBI, the m for mild (although as discussed here the ramifications can be anything but mild) on the specturm of this injury.
With regard to the other study you mentioned, I have not read it but I also wonder if those who start out with lower IQs do not have as much ability to adapt when they sustain an injury so the defecits remain more pronounced.
Dr. Benford:
Here’s an article on the imaging study: Mild Brain Injury Lesions Found with MRI, http://www.medpagetoday.com/MeetingCoverage/AAN/37841
“Increasing use of MRI following mild traumatic brain injury (TBI) is uncovering the nature and location of the specific lesions characteristic of the injury and helping to elucidate treatment possibilities, researchers reported.”
“20% had cerebral punctate microbleeds, which were found in areas such as the gray matter-white matter junction”
“Those lesions are characteristic of diffuse axonal injury”
“linear-oriented streak-like lesions were found in 33% of patients, primarily in the frontal lobes and parasagittal white matter; these lesions differ from the microbleeds in that they may represent injury to the vasculature”
“These two types of lesions had been identified histopathologically post mortem in patients with severe TBI, but until recently, the imaging correlates had not been demonstrated after milder injury.”
Here’s the news release: Study: Brain Imaging After Mild Head Injury/Concussion Can Show Lesions http://www.aan.com/press/index.cfm?fuseaction=release.view&release=1156
Thank you for forwarding the press release to me. Interesting data but I am left with more questions than answers. It looks like the study will be presented tomorrow and I would like to see all of the data. As you are aware, we now know that patients with concussion do have structural damage to their brain. It has been presumed that this damage is at the cellular level and that our current, readily available methods of imaging the brain could not identify these cellular injuries. We have known for a while that more severe injuries can be seen with MRI. As mentioned previously, concussion and diffuse axonal injury are on the same spectrum as far as the mechanism of injury but they are on opposite ends of this spectrum, and everything in between is still classified as mTBI. The questions I have after reading this news article are how symptomatic these patients were and the severity of trauma they had. This would help in determining if these patients could really be classified as only having a concussion and not a more significant form of mTBI, or is the imaging getting so much better that we now can identify the injury pattern in a patient with only concussion type symptoms. In the end it is going to be an argument about semantics, which mTBI pts only have a concussion and which patients have a more significant injury, closer to the diffuse axonal injury side of the spectrum and where do you draw that line. I hope that was not too confusing.
Your welcome. Agree that it would be interesting to see more information/data for the study. Although it is often said that a concussion is a concussion, some of the more recent research seems to be indicating (to me at least) that head injuries exist on a spectrum that may not yet be fully defined or understood, starting at the sub-concussive level. I certainly hope that your average youth athlete is not sustaining injuries which would show these types of lesions with imaging. Hopefully more information will be available after the study is presented.
Here is a new tool that covers all components to concussion management from the 2012 Zurich consensus. It is a concussion management tool, designed and developed in conjunction with the Cleveland Clinic called C3 Logix. http://www.c3logix.com